Summary guidance on adapting diabetes medication for low carbohydrate management of type 2 diabetes
| Drug group | Hypo risk? | Clinical suggestion |
|---|---|---|
| Sulphonylureas (for example, gliclazide) and meglitinides (for example, repaglinide) | Yes | Reduce/stop (if gradual carbohydrate reduction then wean by halving dose successively) |
| Insulins | Yes | Reduce/stop. Typically wean by 30–50% successively. Beware insulin insufficiencya |
| SGLT2 inhibitors (flozins) | No | Ketoacidosis risk if insulin insufficiency. Usually stop in community setting |
| Biguanides (metformin) | No | Optional, consider clinical pros/cons |
| GLP-1 agonists (-enatide/-glutide) | No | Optional, consider clinical pros/cons |
| Thiazolidinediones (glitazones) | No | Usually stop, concerns over long-term risks usually outweigh benefit |
| DPP-4 inhibitors (glipitins) | No | Usually stop, due to lack of benefit |
| Alpha-glucosidase inhibitors (acarbose) | No | Usually stop, due to no benefit if low starch/sucrose ingestion |
| Self-monitoring blood glucose | N/A | Ensure adequate testing supplies for patients on drugs that risk hypoglycaemia. Testing can also support behaviour change (for example, paired pre- and post-meal testing) |
↵a Caution should be taken when reducing insulin if there is clinical suspicion of endogenous insulin insufficiency (Patients with LADA misdiagnosed as T2D; a minority of T2 patients have endogenous insulin deficiency). Consider these possibilities if patient was not overweight at diagnosis. Exogenous insulin should not be completely stopped in these cases. Inappropriate over-reduction of exogenous insulin will lead to marked hyperglycaemia. Hypo = hypoglycaemia. LADA = latent autoimmune diabetes in adults. T2D = type 2 diabetes.